Khat: A Review of Its Potential Harms to the Individual and Communities in the UK PDF
Preview Khat: A Review of Its Potential Harms to the Individual and Communities in the UK
ACMD Advisory Council on the Misuse of Drugs Khat: A review of its potential harms to the individual and communities in the UK 1 Acknowledgements The ACMD wishes to thank the various organisations and individuals who gave their valuable time and attended the evidence gathering days, and those who issued invitations for us to see at first hand their work in this area, as well as to voice their concerns. To aid the work of the ACMD community visits were made to local authorities and NGOs in London, Cardiff and Manchester, which included presentations from Police, NHS bodies and BME groups1. A number of MPs provided representations on the issue of khat use and submitted the views of their constituents. In particular we wish to thank Professor David Anderson for his valuable contribution, as a co-opted member of the Working Group. Dr Hew Mathewson, CBE Co-Chair Kyrie James Co-Chair Professor Fabrizio Schifano, Psychiatrist Chair in Clinical Pharmacology and Therapeutics, University of Hertfordshire Professor Harry Sumnall Professor in Substance Use Centre for Public Health Liverpool John Moores University Mr Arthur Wing Management Adviser (formerly Director of Interventions, Surrey and Sussex Probation Trust) Professor David Anderson Professor of African Politics St Cross College Oxford University 1 The term BME (Black Minority Ethnic) used in this report includes Ethiopian, Somali, Yemeni, Kenyans, Eritreans, and Arabic people, unless otherwise stated. 2 ACMD Advisory Council on the Misuse of Drugs Chair: Professor Les Iversen Secretary: Rachel Fowler 3rd Floor (SW), Seacole Building 2 Marsham Street London SW1P 4DF Tel: 020 7035 0555 [email protected] Rt Hon. Theresa May, MP 2 Marsham Street London SW1P 4DF 23 January 2013 Dear Home Secretary, Thank you for your previous correspondence in which the Minister responsible for Drugs requested, on behalf of Government, that the ACMD review khat, specifically concerning its societal harms. As you are aware, it was agreed with the Home Office the review was necessarily deferred due to competing work priorities. The ACMD has now completed its review and has pleasure in submitting the attached for your consideration. The ACMD has been inclusive in its gathering of the evidence to provide this comprehensive review. The ACMD recognises the concerns that have been raised around the social harms of khat and has therefore gone to lengths to ensure the various sources of this evidence have been collected. As well as peer review articles, surveys and other sources of information on social harms, the ACMD has undertaken community BME visits and has had discussions with Council leaders, as well as requesting information from Government bodies, to ensure the ACMD understood, captured and addressed the relevant concerns. The ACMD last provided you with advice on khat in 2005. The ACMD‘s present assessment that you commissioned builds on the evidence base of the 2005 report, particularly societal harms. In summary, the evidence shows that khat has no direct causal link to adverse medical effects, other than a small number of reports of an association between khat use and significant liver toxicity. 3 Some of the adverse outcomes are associated with khat use i.e. a complex interaction of khat with other factors to produce the outcome, but not directly caused by khat use. It is apparent from the evidence on societal harms that it is often difficult to disentangle whether khat is the source of community problems or, to some extent, its prevalence and use is symptomatic of the problems for some individuals and groups within the community. On the basis of the available evidence, the overwhelming majority of Council members consider that khat should not be controlled under the Misuse of Drugs Act 1971. In summary the reason for this is that, save for the issue of liver toxicity, although there may be a correlation or association between the use of khat and various negative social indicators, it is not possible to conclude that there is any causal link. The ACMD considers that the evidence of harms associated with the use of khat is insufficient to justify control and it would be inappropriate and disproportionate to classify khat under the Misuse of Drugs Act 1971. In summary the ACMD considers that the harms of khat does not reach the level required for classification. Therefore, the ACMD recommend that the status of khat is not changed. We hope there will be close attention paid to the ACMD‘s further recommendations, which all have our unanimous support. It is essential that communities be supported and given the appropriate resource and environment within which they can manage issues e.g. to support integration and address inequalities of health. A multi agency approach, requiring cross departmental consideration, will be essential to address the wider community issues that are well referenced in this report. Our recommendations are based on a rigorous and systematic process of evidence gathering and subsequent analysis of what was submitted and presented to the ACMD. We would welcome discussing our findings with you. Yours sincerely, Kyrie Ll James Professor Les Iversen CBE, Dr Hew Mathewson CBE FRS CC: Minister of State for Crime Prevention Parliamentary Under Secretary of State for Public Health 4 Contents Executive summary 7-11 1. Introduction 12-17 Background 12 Role of the ACMD 13 Remit of review and scope 14 Steps taken to implement recommendations from 2005 report 14-16 Quality of research and hierarchies of evidence 16-17 2. Khat 18-27 Khat use – Global 20 International comparisons 21-23 Khat use – UK 24-27 3. The Pharmacology of Khat 28-30 The active ingredients 28 Pharmacokinetics and pharmacodynamics 29 Mechanism of action 30 4. Medical Harms 31-44 Dependence 32-35 Cardiovascular effects 35-36 Respiratory system effects 37 Oral and gastrointestinal system pathologies 37-38 Liver 38-39 Pregnancy 40 Psychiatric effects 40-42 Cognitive impairment 42-43 Links to mortality 43 Summary on medical harms 44 5. Overview of the Societal Harms associated with khat use 45-57 Unemployment 46-47 Family breakdown 47-48 Income diversion 49 Consumption by young persons 49-50 Consumption by women 51 Anti-social behaviour 52-53 Violence 53-54 Crime and criminal networks 54-56 Integration 56 Summary on social harms 57 5 6. International Issues 58-66 Legislation 58-59 Legislation by Country 60 Australia 61 Canada 61-62 Denmark 62 The Netherlands 63 Norway 63-64 Sweden 64-65 United States of America 65-66 Summary on international issues 66 7. Education and Prevention 67-70 8. Treatment of Khat Use 71-75 Treatment of dependency 73 Implications for khat treatment and recovery interventions 73-75 9. Concerns: communities and groups 76-81 10. Summary and recommendations 82-88 Annex A – Quality of Research and Hierarchies of Evidence 89-90 Annex B – List of Contributors 91-93 Annex C - ACMD Members 94-95 Annex D – Education and Prevention Template 96-97 6 Executive Summary Introduction Khat is a herbal product consisting of the leaves and shoots of the shrub Catha edulis. It is chewed to obtain a mild stimulant effect and is a less potent stimulant than other commonly used drugs, such as amphetamine or cocaine. Khat is not controlled under the Misuse of Drugs Act 1971 and is currently imported and used legally in the UK. Khat is imported into the UK from the main khat growing regions of Kenya, Ethiopia and Yemen. Generally, khat chewing is a social event which takes place within family homes, community parties and at khat cafes. Traditionally khat has been used as a medicine and was widely perceived to be a food, not a drug. Background The ACMD reviewed the harms associated with khat use in 2005 and determined that khat should not be controlled under the Misuse of Drugs Act 1971 and made a number of education and research recommendations. The Minister responsible for drugs requested the ACMD to review and update its assessment of 2005 and provide advice in relation to control under the Misuse of Drugs Act 1971. Khat Use – International There are no international comparable prevalence estimates for use of khat and no reliable published evidence as to the rates of khat use in European countries. However within Europe khat use is primarily amongst BME immigrants from the Horn of Africa countries. Rates of khat use appear high among the general populous in Somalia, Yemen and Ethiopia. However prevalence of khat use is far less among the Somali community living in the UK than in the population living in Somalia. 7 Khat Use – UK Based on VAT data from HM Revenue and Customs there has been a reduction of importation of khat to the UK since 2005. During this period the relevant BME population in the UK has increased by 18.4%. This strongly indicates that khat use within the same UK population has decreased. Northern Ireland and Scotland do not report any figures on prevalence or treatment data of khat users engaging with the NHS. Only 6 referrals are recorded on the Welsh National Database for Substance Misuse since 2009. The NHS data for England for 2010/11 shows 112 clients began treatment for the first time citing involvement with khat at any point in their past. The ACMD is cognisant that NHS and other data may not fully represent the treatment needs of khat users due to the difficulties in engaging with all groups within communities. The Pharmacology of Khat Fresh khat has a short lifespan for use as a chewable stimulant, approximately 36 to 48 hours, from picking to consumption; when transported under optimal conditions. Khat can also be dried and juiced, but both forms have significantly lowered levels of active ingredients, if any at all. Cathinone and cathine isolated in pure form from synthetic compounds are stable and controlled under the Misuse of Drugs Act 1971. This is in direct contrast to the unstable nature of cathinone in the khat plant, which quickly degrades to cathine. It is easier and less expensive to manufacture synthetic cathinones and cathines than to extract it from fresh khat. Although chewing khat is an efficient method of extracting the active ingredient, it is not extracted rapidly, hence the long period of chewing needed to elicit an effect: and it does not have a fast onset of action. Khat‘s bitter taste and method of consumption make it unattractive to most potential consumers. Medical Harms The addictive potential of khat is likely to be less than the consumption of the pure drug cathinone. Khat has no direct causal link to adverse medical effects, other than a small number of reports of an association between khat use and significant liver toxicity. 8 Overall the reporting of physical harms of khat in the media is at odds with the medical evidence. A number of concerns raised may be due to other factors and contributory associations, which should be placed within the wider context of obstacles and lack of opportunities facing the user demographic, overseas nationals and those seeking asylum within our society. Social Harms Anecdotal evidence reported from communities in several UK cities link khat consumption with a wide range of social harms. Research into these concerns has been undertaken but no robust evidence has been found which demonstrates a causal link between khat consumption and any of the harms indicated. Somali groups that made representations to the ACMD claimed khat use was a significant social problem within their local areas and in domestic settings. In contrast it was asserted that the Yemeni community had no problem with khat use, as it takes place within the family setting and is integrated into other social domestic events. The majority of this group use khat in an unproblematic manner. Existing legislative frameworks in health, police and council partnerships working with relevant BME Communities have shown they can successfully address anti- social behaviour concerns voiced. The comparative research undertaken in London and Minneapolis draws attention to the ongoing support upon arrival provided to those arriving in the USA, and how this enhanced employment opportunities, where employment was a key determination for social well being. There is no evidence of khat consumption being directly linked with serious or organised criminal behavior in the UK or to support the theory that khat is funding or fuelling crime. This is unsurprising given khat is not an illegal drug, is not a high value substance and therefore attracts very little profit from the UK market. In regard to international crime the ACMD has not been provided with any evidence of Al Shabaab or any other terrorist group‘s involvement in the export or sale of khat despite consultation with national and international official bodies. Evidence presented to the ACMD by researchers found no link between gang crime and khat use 9 International Issues Legislation regarding khat in Europe and North America has been widely introduced. It appears that decisions to control khat are likely not to have been based on robust evidence of either physical or societal harms, including issues of domestic and international crime, but other factors. The impact of legislation is difficult to measure, however there remains a demand for khat even in those countries where it is prohibited. The outcomes of enforcement are mixed and appear fragmentary in some cases. Fears of the UK becoming a hub for importation of khat appear not borne out by the VAT figures provided by the HMRC regarding the volume of khat imported into the UK since 2005 or by any evidence suggesting the UK is a landing point for the onward transportation of significant quantities of khat. Concerns BME groups are not homogenous communities, but range from well settled fourth generation families to asylum seekers fleeing civil war. The complex multi-factorial issues facing khat using asylum seekers/refugees may include: unemployment; legal uncertainties and irregular status; trauma; no social or family networks; social dislocation; discrimination; poor English literacy; gender politics; lack of inspirational realisation; devalued refugee identity; lack of validation of previous qualifications; lack of or limited access to accommodation and health care service provision. Recommendations Without the necessary data and robust evidence to support proportionate intervention, the ACMD does not recommend that khat be controlled under the Misuse of Drugs Act 1971. The ACMD considers that the ‗coalescence of concerns‘ around the use of khat can be addressed through the recommendations made. 1. The ACMD recommends that the status of khat is not changed and is not controlled under the Misuse of Drugs Act 1971. 10
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